Unintended exposure in radiotherapy: Identification of prominent causes

Boadu, Mary; Rehani, Madan M.

doi:10.1016/j.radonc.2009.08.044

Cited by 35 publications

(25 citation statements)

References 14 publications

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“…As a result, a QA methodology was created that narrowly focused on mechanical functionality and dosimetric accuracy 2. However, retrospective root‐cause analyses of serious radiotherapy incidents have demonstrated that a large percentage of errors occur because of failures in clinical process 3. While device‐specific QA continues to play a critical role, it is now clear that an effective modern quality management program must evaluate the entire clinical process as a complex system prone to human and communication errors.…”

Section: Introductionmentioning

confidence: 99%

Failure mode and effects analysis: A community practice perspective

Schuller

Burns

Ceilley

et al. 2017

J Applied Clin Med Phys

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PurposeTo report our early experiences with failure mode and effects analysis (FMEA) in a community practice setting.MethodsThe FMEA facilitator received extensive training at the AAPM Summer School. Early efforts focused on department education and emphasized the need for process evaluation in the context of high profile radiation therapy accidents. A multidisciplinary team was assembled with representation from each of the major department disciplines. Stereotactic radiosurgery (SRS) was identified as the most appropriate treatment technique for the first FMEA evaluation, as it is largely self‐contained and has the potential to produce high impact failure modes. Process mapping was completed using breakout sessions, and then compiled into a simple electronic format. Weekly sessions were used to complete the FMEA evaluation. Risk priority number (RPN) values > 100 or severity scores of 9 or 10 were considered high risk. The overall time commitment was also tracked.ResultsThe final SRS process map contained 15 major process steps and 183 subprocess steps. Splitting the process map into individual assignments was a successful strategy for our group. The process map was designed to contain enough detail such that another radiation oncology team would be able to perform our procedures. Continuous facilitator involvement helped maintain consistent scoring during FMEA. Practice changes were made responding to the highest RPN scores, and new resulting RPN scores were below our high‐risk threshold. The estimated person‐hour equivalent for project completion was 258 hr.ConclusionsThis report provides important details on the initial steps we took to complete our first FMEA, providing guidance for community practices seeking to incorporate this process into their quality assurance (QA) program. Determining the feasibility of implementing complex QA processes into different practice settings will take on increasing significance as the field of radiation oncology transitions into the new TG‐100 QA paradigm.

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Section: Introductionmentioning

confidence: 99%

Failure mode and effects analysis: A community practice perspective

Schuller

Burns

Ceilley

et al. 2017

J Applied Clin Med Phys

View full text Add to dashboard Cite

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“…It is now becoming more complicated, due to the advent of advanced treatment techniques such as intensity‐modulated radiation therapy (IMRT) and volumetric‐modulated arc therapy (VMAT). Though a downward trend in radiotherapy incident rates has been indicated by several reports, ( 1 , 2 ) severe incidents with detrimental effects, including death, have been reported recently and received public attention (3) . Radiotherapy is a complicated multistep, multiperson process and errors can occur at any point.…”

Section: Introductionmentioning

confidence: 99%

Prevention of gross setup errors in radiotherapy with an efficient automatic patient safety system

Yan

Mittauer

Huang

et al. 2013

J Applied Clin Med Phys

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Treatment of the wrong body part due to incorrect setup is among the leading types of errors in radiotherapy. The purpose of this paper is to report an efficient automatic patient safety system (PSS) to prevent gross setup errors. The system consists of a pair of charge‐coupled device (CCD) cameras mounted in treatment room, a single infrared reflective marker (IRRM) affixed on patient or immobilization device, and a set of in‐house developed software. Patients are CT scanned with a CT BB placed over their surface close to intended treatment site. Coordinates of the CT BB relative to treatment isocenter are used as reference for tracking. The CT BB is replaced with an IRRM before treatment starts. PSS evaluates setup accuracy by comparing real‐time IRRM position with reference position. To automate system workflow, PSS synchronizes with the record‐and‐verify (R&V) system in real time and automatically loads in reference data for patient under treatment. Special IRRMs, which can permanently stick to patient face mask or body mold throughout the course of treatment, were designed to minimize therapist's workload. Accuracy of the system was examined on an anthropomorphic phantom with a designed end‐to‐end test. Its performance was also evaluated on head and neck as well as abdominalpelvic patients using cone‐beam CT (CBCT) as standard. The PSS system achieved a seamless clinic workflow by synchronizing with the R&V system. By permanently mounting specially designed IRRMs on patient immobilization devices, therapist intervention is eliminated or minimized. Overall results showed that the PSS system has sufficient accuracy to catch gross setup errors greater than 1 cm in real time. An efficient automatic PSS with sufficient accuracy has been developed to prevent gross setup errors in radiotherapy. The system can be applied to all treatment sites for independent positioning verification. It can be an ideal complement to complex image‐guidance systems due to its advantages of continuous tracking ability, no radiation dose, and fully automated clinic workflow.PACS number: 87.55.Qr

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“…2 In a study of internally reported clinical incidents at a large academic center from 2007 to 2009, 41 of 176 critical incidents were related to an incorrect setup, wrong patient treatment, or a geographic miss of the target. 3 A 21% error incidence resulting from incorrect setup was found from a study of 100 reported unintended radiation therapy exposures. 4 It is believed that reported clinical error rates may underestimate the true rate, because not all errors are detected in the clinical workflow.…”

Section: Introductionmentioning

confidence: 99%